Skin and Beauty

Onychomycosis - Fungal Infection of Nails, Its Patterns and Treatment

Written by
Dr. Suvash Sahu
and medically reviewed by iCliniq medical review team.

Published on Mar 08, 2017 and last reviewed on Oct 10, 2019   -  2 min read



Most of the patients in dermatological practice who present with nail infections, come with an expectation that it gets cured in the first visit itself. But, due to the slow growth of nail plate and deeper involvement of nail matrix, it requires treatment for longer duration. In this article, I have discussed about fungal infection of the nails.

Onychomycosis - Fungal Infection of Nails, Its Patterns and Treatment

Onychomycosis includes nail infections due to dermatophytes, non-dermatophytes and yeasts as well. Dermatophyte infection of the nail plate is known as tinea unguium. It occurs due to the same species that causes tinea pedis (fungal infection of the feet) and tinea manuum (fungal infection of the hand) and coexist with them, seldom occurring before puberty.

Patterns of Onychomycosis

There are three types of onychomycosis:

  1. Distal subungual onychomycosis (DSO).
  2. White subungual onychomycosis (WSO).
  3. Proximal subungual onychomycosis (PSO).

Distal subungual onychomycosis is the most common variety. It starts when dermatophytes invade the stratum corneum of the hyponychium (thickened portion of skin, underlying the free edge of the nail plate) and distal nail bed to later reach the ventral surface of the nail plate. Whitish or brownish discoloration of the free edge of the nail, subungual hyperkeratosis (thickened material below the nail plate) and even separation of the nail plate from the nail bed can occur.

White superficial onychomycosis involves dorsal part of toenails as white, opaque and sharply demarcated rough areas.

Proximal subungual onychomycosis is the least common type. It starts with fungal invasion of the proximal nail fold and may subsequently extend to the nail plate. It can be associated with HIV infection or AIDS (acquired immunodeficiency syndrome).

Certain Facts About Fungal Nail Disease

  • Onychomycosis is usually caused by dermatophytes (85% to 90%), but several fungi that are difficult to treat affect the toenails.
  • Paronychia (soft tissue infection around a fingernail) is caused by many Candida species and some are resistant to azole drugs.
  • Samples for testing nail fungus should be taken as proximally as possible.
  • Demonstration of hyphae in a nail specimen is sufficient to start treatment.
  • Microscopy and culture, often negative, are unreliable to diagnose tinea unguium.
  • Choice of treatment depends on many factors including age, patient’s preference, infecting fungus, number of nails affected, degree of nail involvement, whether toenails or fingernails are affected and other drugs being taken.


1. Topical Antifungal Agents:

Amorolfine 5% and Ciclopirox 8% nail lacquers have better penetration through the nail plate. It can be used alone or in combination with oral antifungal agents, depending on the number and severity of nail involvement.

2. Oral Antifungal Agents:

Griseofulvin, Fluconazole, Itraconazole and Terbinafine are used. The dosage differs in case of fingernails and toenails. In case of fingernail infection, Griseofulvin 500 mg once daily for six months or Fluconazole 150 mg per week for 3 months or Itraconazole 200 mg twice daily for a week for two months or Terbinafine 250 mg once daily for six weeks.

In case of toenail infection, Griseofulvin 500 mg once daily for 12 months or Fluconazole 150 mg per week for 6 months, Itraconazole 200 mg twice daily for a week for three months or Terbinafine 250 mg once daily for 12 weeks. Griseofulvin is no longer in vogue due to the problem of resistance.

To know more about onychomycosis, consult a fungal infection specialist online -->

Last reviewed at:
10 Oct 2019  -  2 min read


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